Long-Term Care Survey Alert

The Centers for Medicare & Medicaid Services recently shared some key information about how nursing facilities should view and manage the publicly reported quality measures.

In November, CMS will begin posting every Medicare-Medicaid certified nursing facility's' scores on 10 quality measures (see article 5) on its Nursing Home Compare Web site. Consumers will be able to see how a particular facility's scores stack up against state and national averages in what CMS intends to be "one piece" of information to guide the public in selecting nursing home care.

Even so, providers should not view the minimum data set-derived QMs as "benchmarks, guidelines, a threshold or standards," said Barbara Paul, director of CMS' Quality Measurement and Health Assurance group during the agency's Sept. 20 webcast on the Nursing Home Quality Initiative.

"CMS is allowing consumers to compare facilities to each other, but we aren't providing any ranking or saying there is some threshold where everyone should be," Paul told viewers. She goes on to emphasize, however, that researchers have found that facilities scoring at the "better end" on the QMs consistently demonstrated more of certain care practices than their poor scoring counterparts.
(For a review of these practices, see the appendices of the CMS-commissioned study at www.cms.hhs.gov/providers/nursinghomes/nhi/PreReport3_20.pdf.)

CMS also urges facilities to work with state quality improvement organizations to learn the differences between the quality measures and quality indicators (see below for a comparative list). That's because in many ways the two sets of measures are like apples and oranges, and will reveal different information about the care in a facility.

For example, facilities are used to working with the quality indicators, which provide more of a "real time" snap shot of the facility's clinical care for quality improvement purposes. By contrast, the QMs will always reflect minimum data set information that's three to six months old, Paul noted.

Even in cases where the QMs and QIs appear to focus on the same clinical issues, there often are critical differences.

For example, the QI for infection only includes urinary tract infections, while the QM that looks at infection includes residents with UTIs and a broad spectrum of infections and even fever (see article 5).

A provider calling in during the webcast pointed out that facilities with a lot of frail elderly residents with chronic infections, or facilities that are very diligent in assessing infections, may score poorly on this quality measure. Paul countered, however, that the infection QM excludes residents admitted with infections. The measure also excludes residents with end-stage disease and those receiving hospice care.

And CMS has taken additional steps to risk adjust some of the QMs to promote fairness. For example, CMS is risk adjusting the pressure ulcer QM based on a facility's admission profile to avoid penalizing facilities that specialize in wound care.

Conversely, CMS has "upped the notch" on the pain QM so that facilities with many cognitively impaired residents won't be compared to those with patients who are more likely to verbalize their pain, Paul told viewers.

CMS plans to examine the issue of whether the QMs should be cast in a more positive light. Currently, only one QM focuses on a positive outcome; i.e., improvement in walking from the 5-day to the 14-day MDS assessment. The agency also will consider including measures that address resident and family satisfaction with a facility.

Trade groups have long pressed for such changes to a public reporting system for nursing homes. "Focusing on what the facility does well rather than the possible problems would encourage providers and consumers to strive for excellence rather than simply seeking to avoid the worst," says Ruta Kadonoff, a health policy analyst for the American Association of Homes & Services for the Aging.

There are other changes on the horizon: At some point, the QMs and related best practices developed by QIOs may be incorporated more into the survey process, according to Angela Brice-Smith, deputy director of CMS' Survey and Certification Group. CMS will also be releasing its new MDS in 2004, which is being developed with the QM work already in place.